Gonorrhoea cases on the rise

The burden of gonorrhoea, a sexually transmitted infection (STI) is increasing in Bhutan, a recent study conducted by health officials revealed.

The study, ‘Burden of gonorrhoea and trends in antibiotic susceptibility pattern of Neisseria gonorrhoea in Bhutan over four years’ was published on April 22 this year.

The study was conducted in four largest hospitals in the country that has microbiology culture facilities – the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Mongar Regional Referral Hospital, Gelephu Central Regional Referral Hospital and Phuentsholing General Hospital.

Lead author, Dr Tshokey, said the study involved the analysis of laboratory data in the four hospitals from 2012 to 2015.

Gonorrhea is a sexually transmitted infection caused by the Neisseria gonorrhoea bacteria and remains a significant public health problem worldwide. The study supplements the health ministry’s annual health reports, which state that the overall sexually transmitted infections increased from 12 in every 10,000 people in 2011 to 92 in every 10,000 people in 2015.

In this research, the total gonorrhoea cases tested in the four hospitals were 336 in 2012, with a small dip in 2013 at 316 but increasing to 490 in 2014 and 716 in 2015.

The study, however, states that because the research only included patients who were tested in the laboratories, there is possibility that the actual number may be higher. It stated that because a good number of patients do not come to hospitals in the first place, especially in the bordering areas where they seek medication from medical shops across the border. Some also refuse to come to the laboratory for testing and get the medications directly, even when a doctor prescribes a laboratory test.

Gonorrhoea, the research states, is mostly managed syndromically based on clinical diagnosis in the country.

“Bhutan has never conducted any antibiotic resistance surveillance to determine the local antibiotic resistance level to guide the development of standard treatment guidelines for gonorrhoea and national treatment guidelines have always been adapted from regional WHO guidelines until now,” the study stated.

Treatment of gonorrhoea has evolved over the years as the bacteria become resistant to the antibiotic used within few years of its use.  It states that today, gonorrhoea is treated with a single dose of an antibiotic called ceftriaxone. Recent reports showed the current resistance of N. gonorrhoea to ceftriaxone in Bhutan to be between 0.16 to 2.2 percent.

The research confirmed this finding and reported resistance rate to ceftriaxone at 0.2 percent. “For any antibiotics to be used as a “therapy of choice” against gonorrhoea, the resistance rate should be below 5 percent and our current treatment of choice, ceftriaxone has a resistance level of 0.2 percent, which makes it a good choice,” it stated.

It also found the resistance to antibiotics such as nalidixic acid, ciprofloxacin, penicillin G and tetracycline to be very high. These include some of the older antibiotics used to treat gonorrhoea but can no longer be used since they are no longer effective against the bacteria.

“Fortunately, resistance against ceftriaxone, (the current recommended antibiotic), azithromycin, spectinomycin and cefpodoxime were below the critical resistance rate of 5 percent for an antibiotic to be used as recommended treatment,” the study states.

The study also states that Bhutan can continue to use ceftriaxone as the therapy of choice but well-coordinated, multi-site, antibiotic resistance surveillance, especially against ceftriaxone is required as resistance towards ceftriaxone continue to emerge and spread worldwide.

“Such ongoing surveillance would alert and guide in recommending continued use of ceftriaxone at the same or higher or multiple dosages or combined therapy or an overall change of recommended therapy to N. gonorrhoea in the future, as already recommended in some countries,” the study stated.

The study also found that healthcare workers might not be practising “partner tracing and treatment” which is highly advocated in the STI treatment guideline. “Of the 1,858 patients tested in the four hospitals over four years, only 48, 2.6 percent, were female patients,” the report stated. “If for every male patient, the female partner is traced, tested and treated, the number of females should be almost equal or at least not so lower than males.” The study was published in in the International STD Research & Reviews.

Tashi Dema

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